RETURN FORMS TO THE ACTIVITY CENTER AT BOHRER PARK
Thursdays - Oct 1 - Nov 5, 2015
2:45 - 4:15pm
*Lesson is from 3:00-4:00pm
Meet at Activity Center at Bohrer Park
(Next to GHS)
506 S Frederick Ave
Gaithersburg, MD 20877
Shuttle provided to/from Gaithersburg Aquatic Center.
Learn how to swim or perfect your swim strokes.
Student Union Members
Participants MUST wear a bathing suit in the pool.
Bring a towel and a change of dry clothes.
$10.00
Students can ride the shuttle back to the Activity Center
after lessons, or are welcome to come to the GYC.
SPACE IS LIMITED! REGISTER EARLY!
Questions? Contact Maura Dinwiddie at 301-258-6350
[email protected]
Swim Lessons: October 1 - November 5
□ Check here if new address/phone since last time registered.
Parent’s Last Name__________________________________ Parent’s First Name__________________________
Address _____________________________________City/State/Zip_____________________________________
Home Phone_____________________ Work Phone _______________________ City Resident □ Nonresident □
Email ____________________________________________
Participant’s Name
Sex
M/F
Birthdate
M/D/Y
Activity Name
Activity
#
Location
Start
Date
Swim Lessons
42986
ACBP/GAC
10/1/15
Swim Lessons
42986
ACBP/GAC
10/1/15
Grade
School
I hereby grant permission for me/my child to attend the activity sponsored by the City of Gaithersburg. I understand that I am responsible
for my/my child’s insurance in case of injury. Furthermore, I understand that although safety precautions will be observed, the City of
Gaithersburg, employees and agents will not be responsible for any personal property lost by me/my child or any injury sustained in the
program. I also consent to the City’s use of any photographs an/or video tapes made of the program.
__________________________________________
Print Parent/Guardian Name
________________________________________
Signature of Parent/Guardian
Does your child have any allergies, medications or conditions that may affect participation in the program? Y□ N □
Please specify:
______________________________________________________________________________________________
Amount Paid $ ________________ Cash □ Check # ____________
Visa/MC# ___________________________ Exp. Date ___/___
Signature (name on card) ______________________________
Print Name__________________________________________
Office Use Only: # 42986
Rec’d:_________ Initials _______
W P M F Resident: Y N
Pr: ___________ Date:__________